Select a scenario: Which bleeding situation is being managed?

DOAC

This is a scenario-based simulator. No patient information should be entered, and the tool does not record what you enter.

What is the situation?

Bleed on DOAC

What is the type of bleed?

Minor Bleeding

Minor BleedFor example: extremity bruising, hemorrhoidal bleeding, subconjunctival bleed, self-limited epistaxis.

Is minor bleed confirmed?

Yes

Last updated: 16-JUL-2026

Source

Thrombosis Canada, 2025

No PCC is approved in Canada for this indication

Manage

Minor bleeding on DOAC

1
Continue DOAC and monitor
2
Confirm the patient is receiving the appropriate drug and dose based on indication, age, weight, creatinine clearance, co-medications.
3
Consider measuring hemoglobin, platelet count, creatinine, and liver function tests
4
Review concomitant medications which may contribute to bleeding (e.g. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)

As directed by protocol

Is management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

1
Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making
2
Confirm ongoing indication for anticoagulation.
3
Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.
4
Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.
5
Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)
6
Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.
7
Provide education and counselling regarding bleeding complications and when to seek medical attention.
8
Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

AcknowlegementsAdapted from Thrombosis Canada clinical guide "DOACs: Management of Bleeding" with clinical oversight by Dr. Joseph Shaw.

Clinically relevant non-major bleeding

Clinically relevant non-major bleedingNon-life-threatening bleeding that requires medical attention and/or non-urgent intervention (i.e. hemodynamically stable chronic gastrointestinal bleed, epistaxis, hematuria, or menstrual bleeding)

Is clinically relevant non-major bleeding confirmed?

Yes

What is the DOAC?

Apixaban

Which laboratory tests are available?

PT/INR
aPTT
Heparin or LMWH anti-Xa
Calibrated anti-Xa

When was the timing of the last DOAC dose?

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Clinically relevant non-major bleed on Apixaban

1
Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management
See disclaimer
2
Determine: whether clinically significant levels of DOAC are likely to be present

NOTEAs directed by protocol

PT/INR

IFTHEN

Normal
does NOT exclude a clinically significant FXaI level
Increased
May indicate a clinically significant FXaI level

IF

Normal

THEN

does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

May indicate a clinically significant FXaI level

aPTT

IFTHEN

Normal
Does NOT exclude a clinically significant FXaI level
Increased
may indicate a clinically significant FXaI level

IF

Normal

THEN

Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IFTHEN

<0.1 IU/mL
likely no clinically significant FXaI level
>0.1 IU/mL
possible clinically significant FXaI level
(assay dependent)

IF

<0.1 IU/mL

THEN

likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN

possible clinically significant FXaI level

(assay dependent)

Calibrated anti-Xa

Calibrated FXaI level

IFTHEN

<50 ng/mL
FXaI level less likely to be significantly contributing to impaired hemostasis
>50 ng/mL
FXaI level is likely to be significantly contributing to impaired hemostasis

IF

<50 ng/mL

THEN

FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN

FXaI level is likely to be significantly contributing to impaired hemostasis

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Apixaban dose:
- —
Creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 7-17 hours
CrCl 30– 49 mL/min
Half-life is 17 – 20 hours
2
If indicated, administer transfusion therapies as per guidelines.
3
Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

NOTEAs directed by protocol

Is management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

1
Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making
2
Confirm ongoing indication for anticoagulation.
3
Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.
4
Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.
5
Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)
6
Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.
7
Provide education and counselling regarding bleeding complications and when to seek medical attention.
8
Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

As directed by protocol

Scenario complete

Reset to start over or to select another scenario

AcknowledgementsAdapted from Thrombosis Canada clinical guide "DOACs: Management of Bleeding" with clinical oversight by Dr. Joseph Shaw.

Edoxaban

Which laboratory tests are available?

PT/INR
aPTT
Heparin or LMWH anti-Xa
Calibrated anti-Xa

When was the timing of the last DOAC dose?

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Clinically relevant non-major bleed on Edoxaban

1
Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management
See disclaimer
2
Determine: whether clinically significant levels of DOAC are likely to be present

As directed by protocol

PT/INR

IFTHEN

Normal
does NOT exclude a clinically significant FXaI level
Increased
May indicate a clinically significant FXaI level

IF

Normal

THEN

does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

May indicate a clinically significant FXaI level

aPTT

IFTHEN

Normal
Does NOT exclude a clinically significant FXaI level
Increased
may indicate a clinically significant FXaI level

IF

Normal

THEN

Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IFTHEN

<0.1 IU/mL
likely no clinically significant FXaI level
>0.1 IU/mL
possible clinically significant FXaI level
(assay dependent)

IF

<0.1 IU/mL

THEN

likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN

possible clinically significant FXaI level

(assay dependent)

Calibrated anti-Xa

Calibrated FXaI level

IFTHEN

<50 ng/mL
FXaI level less likely to be significantly contributing to impaired hemostasis
>50 ng/mL
FXaI level is likely to be significantly contributing to impaired hemostasis

IF

<50 ng/mL

THEN

FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN

FXaI level is likely to be significantly contributing to impaired hemostasis

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Edoxaban dose:
- —
Creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 10-14 hours
CrCl 30– 49 mL/min
2
If indicated, administer transfusion therapies as per guidelines.
3
Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

As directed by protocol

Is management complete and bleeding resolved?

Rivaroxaban

Which laboratory tests are available?

PT/INR
aPTT
Heparin or LMWH anti-Xa
Calibrated anti-Xa

When was the timing of the last DOAC dose?

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Clinically relevant non-major bleed on Rivaroxaban

1
Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management
See disclaimer
2
Determine: whether clinically significant levels of DOAC are likely to be present

As directed by protocol

PT/INR

IFTHEN

Normal
does NOT exclude a clinically significant FXaI level
Increased
May indicate a clinically significant FXaI level

IF

Normal

THEN

does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

May indicate a clinically significant FXaI level

aPTT

IFTHEN

Normal
Does NOT exclude a clinically significant FXaI level
Increased
may indicate a clinically significant FXaI level

IF

Normal

THEN

Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IFTHEN

<0.1 IU/mL
likely no clinically significant FXaI level
>0.1 IU/mL
possible clinically significant FXaI level
(assay dependent)

IF

<0.1 IU/mL

THEN

likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN

possible clinically significant FXaI level

(assay dependent)

Calibrated anti-Xa

Calibrated FXaI level

IFTHEN

<50 ng/mL
FXaI level less likely to be significantly contributing to impaired hemostasis
>50 ng/mL
FXaI level is likely to be significantly contributing to impaired hemostasis

IF

<50 ng/mL

THEN

FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN

FXaI level is likely to be significantly contributing to impaired hemostasis

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Rivaroxaban dose:
- —
Creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 7-11 hours
CrCl 30– 49 mL/min
Half-life is 7-11 hours
2
If indicated, administer transfusion therapies as per guidelines.
3
Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

Is management complete and bleeding resolved?

Dabigatran

Which laboratory tests are available?

PT/INR
aPTT
dTT or Ecarin time
Thrombin Time

When was the timing of the last DOAC dose?

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Dabigatran dose:
- —
Creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 7-17 hours
CrCl 30– 49 mL/min
Half-life is 17-20 hours
2
If indicated, administer transfusion therapies as per guidelines.
3
Seek consultation for investigation and definitive management of bleeding source as appropriate (i.e. endoscopy, interventional radiology, surgery)

NOTEAs directed by protocol

Is management complete and bleeding resolved?

Major bleeding

Major bleeding Severe/life threatening bleeding (i.e. bleeding in a critical area or organ, such as intracranial, intraspinal or epidural, retroperitoneal, intramuscular with actual or impending compartment syndrome, pericardial, gastrointestinal bleeding with hemodynamic instability)

Confirmed major bleeding?

Yes

What is the DOAC?

Apixaban

What laboratory tests do you have available?

PT/INR
aPTT
Heparin or LMWH anti-Xa
Calibrated anti-Xa

When was the timing of the last DOAC dose?

1
Hold: DOAC therapy
2
Initiate: resuscitation in a monitored setting
3
Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)
4
Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)
5
STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Major bleed on Apixaban

1
Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management
See disclaimer
2
Determine: whether clinically significant levels of DOAC are likely to be present

PT/INR

IFTHEN

Normal
does NOT exclude a clinically significant FXaI level
Increased
May indicate a clinically significant FXaI level

IF

Normal

THEN

does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

May indicate a clinically significant FXaI level

aPTT

IFTHEN

Normal
Does NOT exclude a clinically significant FXaI level
Increased
may indicate a clinically significant FXaI level

IF

Normal

THEN

Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IFTHEN

<0.1 IU/mL
likely no clinically significant FXaI level
>0.1 IU/mL
possible clinically significant FXaI level
(assay dependent)

IF

<0.1 IU/mL

THEN

likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN

possible clinically significant FXaI level

(assay dependent)

Calibrated anti-Xa

Calibrated FXaI level

IFTHEN

<30 ng/mL
FXaI level is not significantly contributing to impaired hemostasis
30-50ng/mL
FXaI level less likely to be significantly contributing to impaired hemostasis
>50 ng/mL
FXaI level is likely to be significantly contributing to impaired hemostasis

IF

<30 ng/mL

THEN

FXaI level is not significantly contributing to impaired hemostasis

IF

30-50ng/mL

THEN

FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN

FXaI level is likely to be significantly contributing to impaired hemostasis

<30 ng/mL: Residual FXaI level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.

30 to 50 ng/mL: Residual FXaI level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.

>50 ng/mL: Residual FXaI level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.

Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Apixaban

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Apixaban dose:
- —
Patient’s creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 8-12 hours
CrCl 30– 49 mL/min
Half-life is 8 – 12 hours
2
If clinically significant DOAC levels are likely to be present based on:
- Age
- Weight
- Renal/hepatic function
- Concurrent interacting medications
- Time since last DOAC dose
OR level is confirmed using a FXaI-specific assay (levels over 30 to 50ng/mL) - See Note

Administer PCC

Dose: 2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU
Safety: Contraindicated in patients with a history of heparin-induced thrombocytopenia
Note: PCC is not a specific reversal agent but the only available prohemostatic therapy

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

1
Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making
2
Confirm ongoing indication for anticoagulation.
3
Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.
4
Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.
5
Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)
6
Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.
7
Provide education and counselling regarding bleeding complications and when to seek medical attention.
8
Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

Algorithm complete

Reset to start over or to select another journey

Edoxaban

What laboratory tests do you have available?

PT/INR
aPTT
Heparin or LMWH anti-Xa
Calibrated anti-Xa

When was the timing of the last DOAC dose?

1
Hold: DOAC therapy
2
Initiate: resuscitation in a monitored setting
3
Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)
4
Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)
5
STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Major bleed on Edoxaban

1
Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management
See disclaimer
2
Determine: whether clinically significant levels of DOAC are likely to be present

PT/INR

IFTHEN

Normal
does NOT exclude a clinically significant FXaI level
Increased
May indicate a clinically significant FXaI level

IF

Normal

THEN

does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

May indicate a clinically significant FXaI level

aPTT

IFTHEN

Normal
Does NOT exclude a clinically significant FXaI level
Increased
may indicate a clinically significant FXaI level

IF

Normal

THEN

Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IFTHEN

<0.1 IU/mL
likely no clinically significant FXaI level
>0.1 IU/mL
possible clinically significant FXaI level
(assay dependent)

IF

<0.1 IU/mL

THEN

likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN

possible clinically significant FXaI level

(assay dependent)

Calibrated anti-Xa

Calibrated FXaI level

IFTHEN

<30 ng/mL
FXaI level is not significantly contributing to impaired hemostasis
30-50ng/mL
FXaI level less likely to be significantly contributing to impaired hemostasis
>50 ng/mL
FXaI level is likely to be significantly contributing to impaired hemostasis

IF

<30 ng/mL

THEN

FXaI level is not significantly contributing to impaired hemostasis

IF

30-50ng/mL

THEN

FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN

FXaI level is likely to be significantly contributing to impaired hemostasis

<30 ng/mL: Residual FXaI level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.

30 to 50 ng/mL: Residual FXaI level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.

>50 ng/mL: Residual FXaI level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.

Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Edoxaban

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Edoxaban dose:
- —
Patient’s creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 10-14 hours
CrCl 30– 49 mL/min
Half-life is 10-14 hours
2
If clinically significant DOAC levels are likely to be present based on:
- Age
- Weight
- Renal/hepatic function
- Concurrent interacting medications
- Time since last DOAC dose
OR level is confirmed using a FXaI-specific assay (levels over 30 to 50ng/mL) - See Note

Administer PCC

Dose: 2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU
Safety: Contraindicated in patients with a history of heparin-induced thrombocytopenia
Note: PCC is not a specific reversal agent but the only available prohemostatic therapy

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

1
Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making
2
Confirm ongoing indication for anticoagulation.
3
Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.
4
Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.
5
Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)
6
Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.
7
Provide education and counselling regarding bleeding complications and when to seek medical attention.
8
Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

Algorithm complete

Reset to start over or to select another journey

Rivaroxaban

What laboratory tests do you have available?

PT/INR
aPTT
Heparin or LMWH anti-Xa
Calibrated anti-Xa

When was the timing of the last DOAC dose?

1
Hold: DOAC therapy
2
Initiate: resuscitation in a monitored setting
3
Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)
4
Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)
5
STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

DOAC-specific calibrated anti-Xa assays remain the preferred method for measuring direct factor Xa inhibitor concentrations. LMWH-calibrated anti-Xa assays should not be used interchangeably across centers or assumed to directly provide a DOAC level in ng/mL. Their performance is assay-, reagent-, analyzer-, and drug-specific, and the IU/mL output requires careful local validation before clinical use. Where a center uses an LMWH-calibrated anti-Xa assay as a surrogate for apixaban, rivaroxaban, or edoxaban measurement, the laboratory should provide assay-specific interpretive guidance, including locally validated cutoffs or approximate conversion ranges to clinically relevant DOAC concentrations, the reportable/roughly linear range, and important limitations. This approach should only be used when such local validation and reporting infrastructure are in place.

2 of 3

Major bleed on Rivaroxaban

1
Measure: plasma concentration of DOAC using a specific validated assay (heparin or LMWH anti-Xa, FXaI-specific calibrated anti-Xa) if available with timely results AND the results would change management
See disclaimer
2
Determine: whether clinically significant levels of DOAC are likely to be present

PT/INR

IFTHEN

Normal
does NOT exclude a clinically significant FXaI level
Increased
May indicate a clinically significant FXaI level

IF

Normal

THEN

does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

May indicate a clinically significant FXaI level

aPTT

IFTHEN

Normal
Does NOT exclude a clinically significant FXaI level
Increased
may indicate a clinically significant FXaI level

IF

Normal

THEN

Does NOT exclude a clinically significant FXaI level

IF

Increased

THEN

may indicate a clinically significant FXaI level

Heparin or LMWH anti-Xa

Heparin or LMWH anti Xa

IFTHEN

<0.1 IU/mL
likely no clinically significant FXaI level
>0.1 IU/mL
possible clinically significant FXaI level
(assay dependent)

IF

<0.1 IU/mL

THEN

likely no clinically significant FXaI level

IF

>0.1 IU/mL

THEN

possible clinically significant FXaI level

(assay dependent)

Calibrated anti-Xa

Calibrated FXaI level

IFTHEN

<30 ng/mL
FXaI level is not significantly contributing to impaired hemostasis
30-50ng/mL
FXaI level less likely to be significantly contributing to impaired hemostasis
>50 ng/mL
FXaI level is likely to be significantly contributing to impaired hemostasis

IF

<30 ng/mL

THEN

FXaI level is not significantly contributing to impaired hemostasis

IF

30-50ng/mL

THEN

FXaI level less likely to be significantly contributing to impaired hemostasis

IF

>50 ng/mL

THEN

FXaI level is likely to be significantly contributing to impaired hemostasis

<30 ng/mL: Residual FXaI level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.

30 to 50 ng/mL: Residual FXaI level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.

>50 ng/mL: Residual FXaI level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.

Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Rivaroxaban

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Rivaroxaban dose:
- —
Patient’s creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 7-11 hours
CrCl 30– 49 mL/min
Half-life is 7-11 hours
2
If clinically significant DOAC levels are likely to be present based on:
- Age
- Weight
- Renal/hepatic function
- Concurrent interacting medications
- Time since last DOAC dose
OR level is confirmed using a FXaI-specific assay (levels over 30 to 50ng/mL) - See Note

Administer PCC

Dose: 2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU
Safety: Contraindicated in patients with a history of heparin-induced thrombocytopenia
Note: PCC is not a specific reversal agent but the only available prohemostatic therapy

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

1
Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making
2
Confirm ongoing indication for anticoagulation.
3
Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.
4
Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.
5
Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)
6
Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.
7
Provide education and counselling regarding bleeding complications and when to seek medical attention.
8
Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

Algorithm complete

Reset to start over or to select another journey

Dabigatran

What laboratory tests do you have available?

PT/INR
aPTT
Thrombin time
Dilute TT or ECT

When was the timing of the last DOAC dose?

1
Hold: DOAC therapy
2
Initiate: resuscitation in a monitored setting
3
Apply: local hemostatic measures if appropriate (i.e. compression, packing, suturing)
4
Consult: an expert urgently for advice regarding management of coagulopathy (i.e. hematologist, internist, ER physician, pharmacist) and consult for definitive procedural intervention as applicable (i.e. gastroenterology, interventional radiology, surgery)
5
STAT: laboratory testing for hemoglobin, platelet count, coagulation tests (PT/INR, aPTT), creatinine, liver function tests, group and screen (as appropriate)

<30 ng/mL: Residual Dabigatran level is unlikely to be a major contributor to ongoing impaired hemostasis. At this level, the DOAC effect alone would generally not justify PCC administration, and management should instead focus on local hemostatic measures, supportive care, source control, transfusion support as needed, and the overall clinical context. This threshold does not exclude all bleeding risk, but it suggests that residual anticoagulant effect is less likely to be the main driver of bleeding.

30 to 50 ng/mL: Residual Dabigatran level may still be clinically relevant, but this range should be treated as a gray zone. In many patients, especially those without catastrophic bleeding, PCC may still be deferred. However, PCC can be considered when the clinical situation is especially high risk, such as life-threatening bleeding, bleeding at a critical site such as intracranial hemorrhage, or urgent surgery or intervention with very high bleeding risk that cannot be delayed. In this range, interpretation should be individualized and based on the severity of bleeding, the anatomic site, procedural urgency, and whether a specific reversal agent is available.

>50 ng/mL: Residual Dabigatran level is more likely to be clinically significant and more likely to be contributing meaningfully to impaired hemostasis. In patients with major or life-threatening bleeding, or those requiring urgent or emergency high bleeding risk surgery, this level would support consideration of PCC, particularly when a specific antidote is unavailable. For urgent procedural decision-making, the acceptable threshold may vary with the bleeding risk of the planned intervention, and some situations may justify use of a higher threshold in the 50 to 75 ng/mL range depending on surgical context.

Interpretive note: These thresholds should support, not replace, clinical judgment. Decisions about PCC should still be driven primarily by bleeding severity, bleeding site, procedural urgency, and whether definitive local hemostasis or delay to permit drug clearance is feasible. In general, 50 ng/mL is a reasonable threshold for considering reversal in major bleeding, whereas 30 ng/mL may be considered in particularly severe or life-threatening bleeding.

3 of 3

Major bleed on Dabigatran

1
Determine the expected rate of drug clearance based on:
Time elapsed since last Rivaroxaban dose:
- —
Patient’s creatinine clearance:
- —
- —
And:
CrCl ≥ 50 mL/ min
Half-life is 7-17 hours
CrCl 30– 49 mL/min
Half-life is 17-20 hours
2
If clinically significant DOAC levels are likely to be present based on:
- Age
- Weight
- Renal/hepatic function
- Concurrent interacting medications
- Time since last DOAC dose
OR level is confirmed using a specific assay (levels over 30 to 50ng/mL) - See Note

Administer Idarucizumab

Specific reversal agent

Dose: 5 g IV (2 x 2.5 g vials)

Hemodialysis can be considered as an adjunctive measure if inadequate response to Idarucizumab particularly in the setting of AKI

Note

aPCC may be used if PCC unavailable

Administer PCC

If specific reversal is not available

Dose: 2000 units fixed dose or 25-50 units/kg, maximum single dose of 5000 IU
Safety: Contraindicated in patients with a history of heparin-induced thrombocytopenia

Consult local institutional protocols or hematology/thrombosis for advice as required and inform patients/ families regarding thrombotic risks.

Management complete and bleeding resolved?

Yes

Termination

Bleeding resolved

1
Assess patients for resumption of anticoagulation when hemostasis is achieved with consideration of shared decision making
2
Confirm ongoing indication for anticoagulation.
3
Estimate the risks of recurrent bleeding and thrombosis (and their clinical sequelae) with multidisciplinary input.
4
Re-evaluate laboratory parameters once patient has been clinically stabilized (hemoglobin, platelet count, creatinine, liver function tests) and patient’s weight.
5
Review concomitant medications and reassess the need for medications which may contribute to bleeding (i.e. antiplatelet therapies, NSAIDs, SSRIs, herbal supplements)
6
Confirm the appropriateness of the type and dose of anticoagulant based on clinical characteristics such as indication, age, weight, and creatinine clearance.
7
Provide education and counselling regarding bleeding complications and when to seek medical attention.
8
Ensure routine follow-up and reassessment of #1 to #6 at regular intervals.

Algorithm complete

Reset to start over or to select another journey

Surgery on DOAC

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Trauma

This is a scenario-based simulator. No patient information should be entered, and the tool does not record what you enter.

MHP

INITIATED DUE TO

1
Poor BP response to fluids
2
Massive blood loss
3
Hypotension
4
Likely need plasma

OR local activation criteria

What is the institution type?

Large/ academic hospital

What type of patient is being managed?

Pediatric patient

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g., caesarean section, intra-operative)?

Yes

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

SOURCE

MHP 2.0

Fibryga and Octaplex indicated

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs)

6

Infuse all of “Cooler 1” (20 ml/kg per dose) BEFORE “Cooler 2”, UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2	Cooler 3	Cooler 4+
> 40kg	4U RBC	4U RBC, 4U Octaplasma	4U RBC 2U Octaplasma 4g Fibryga	4U RBC 2U Octaplasma
31-40kg	3U RBC	3U RBC 3U Octaplasma	3U RBC 2U Octaplasma 2g Fibryga	3U RBC 2U Octaplasma
10-30kg	2U RBC	2U RBC 2U Octaplasma	2U RBC 1U Octaplasma 2g Fibryga	2U RBC 1U Octaplasma
<10kg	1U RBC	1U RBC 1U Octaplasma	1U RBC 1U Octaplasma 1g Fibryga	1U RBC 1U Octaplasma

*For coolers 2+ adjust RBC: Plasma ratio 1-2:1 (weight-based dosing) as needed UNTIL lab directed dosing possible.

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	Octaplasma 10-20mL/kg per dose
Fibrinogen <1.5 g/L	Fibryga 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

7
Limit use of crystalloids
8
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/Kg IV (max 3g)

9

Reverse anticoagulation if applicable

Warfarin	Vitamin K 1-10mg (neonate to adolescent) IV over 10 min & Octaplex 15IU/kg for INR <3 (or unknown) & 30IU/kg if INR ≥ 3 (max 5000 IU)
Thrombin/ Factor Xa inhibitors or Heparins	Consult with hematologist and/or call pharmacy for dosing

10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

Yes

Step 2 of 3

Assessment every 30-60 minutes

1
Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable?
2
Is patient’s core temperature >36°C?
3
Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?
4
Administer calcium chloride 20 mg/Kg (max 1 g) or gluconate 60 mg/Kg IV(max 3 g) after each RBC equivalent of one cooler transfused or ionized calcium <1.15 mmol/L
5
Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)
6
Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)
7
Switch to group specific blood products when possible

Can the MHP be deactivated?

Yes

Step 3 of 3

Termination

1
Deactivate MHP as per local policy
2
Perform bedside termination checklist
3
Inform family member and SDM of needing MHP
4
Ensure coolers and unused MHP components are returned to transfusion medicine lab ASAP
5
Complete documentation and hand-over

Algorithm complete

Reset to start over or to select another journey

No

Last updated: 16-JUL-2026

MHP 2.0

Fibryga indicated and Octaplex not indicated

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs)

6

Infuse all of “Cooler 1” (20 ml/kg per dose) BEFORE “Cooler 2”, UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2	Cooler 3	Cooler 4+
> 40kg	4U RBC	4U RBC, 4U Octaplasma	4U RBC 2U Octaplasma 4g Fibryga	4U RBC 2U Octaplasma
31-40kg	3U RBC	3U RBC 3U Octaplasma	3U RBC 2U Octaplasma 2g Fibryga	3U RBC 2U Octaplasma
10-30kg	2U RBC	2U RBC 2U Octaplasma	2U RBC 1U Octaplasma 2g Fibryga	2U RBC 1U Octaplasma
<10kg	1U RBC	1U RBC 1U Octaplasma	1U RBC 1U Octaplasma 1g Fibryga	1U RBC 1U Octaplasma

*For coolers 2+ adjust RBC: Plasma ratio 1-2:1 (weight-based dosing) as needed UNTIL lab directed dosing possible.

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	Octaplasma 10-20mL/kg per dose
Fibrinogen <1.5 g/L	Fibryga 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

7
Limit use of crystalloids
8
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/Kg IV (max 3g)
9
Reverse anticoagulation if applicable
Thrombin/ Factor Xa inhibitors or Heparins
Consult with hematologist and/or call pharmacy for dosing
10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

No

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

SOURCE

MHP 2.0

Octaplex indicated and Fibryga not indicated

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).

6

Transfuse all of “Cooler 1” (20 ml/kg per dose) BEFORE “Cooler 2”, UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2	Cooler 3	Cooler 4+
> 40kg	4U RBC	4U RBC, 4U Octaplasma	4U RBC 2U Octaplasma 4g FC	4U RBC 2U Octaplasma
31-40kg	3U RBC	3U RBC 3U Octaplasma	3U RBC 2U Octaplasma 2g FC	3U RBC 2U Octaplasma
10-30kg	2U RBC	2U RBC 2U Octaplasma	2U RBC 1U Octaplasma 2g FC	2U RBC 1U Octaplasma
<10kg	1U RBC	1U RBC 1U Octaplasma	1U RBC 1U Octaplasma 1g FC	1U RBC 1U Octaplasma

*For coolers 2+ adjust RBC: Plasma ratio 1-2:1 (weight-based dosing) as needed UNTIL lab directed dosing possible.

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	Octaplasma 10-20mL/kg per dose
Fibrinogen <1.5 g/L	FC 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

7
Limit use of crystalloids
8
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/Kg IV (max 3g)

9

Reverse anticoagulation if applicable

Warfarin	Vitamin K 1-10mg (neonate to adolescent) IV over 10 min & Octaplex 15IU/kg for INR <3 (or unknown) & 30IU/kg if INR ≥ 3 (Max 5000 IU)
Thrombin/ Factor Xa inhibitors or Heparins	Consult with hematologist and/or call pharmacy for dosing

10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

No

Last updated: 16-JUL-2026

SOURCE

MHP 2.0

Octaplex and Fibryga not indicated

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs)

6

Transfuse all of “Cooler 1” (20 ml/kg per dose) BEFORE “Cooler 2”, UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2	Cooler 3	Cooler 4+
> 40kg	4U RBC	4U RBC, 4U Octaplasma	4U RBC 2U Octaplasma 4g FC	4U RBC 2U Octaplasma
31-40kg	3U RBC	3U RBC 3U Octaplasma	3U RBC 2U Octaplasma 2g FC	3U RBC 2U Octaplasma
10-30kg	2U RBC	2U RBC 2U Octaplasma	2U RBC 1U Octaplasma 2g FC	2U RBC 1U Octaplasma
<10kg	1U RBC	1U RBC 1U Octaplasma	1U RBC 1U Octaplasma 1g FC	1U RBC 1U Octaplasma

*For coolers 2+ adjust RBC: Plasma ratio 1-2:1 (weight-based dosing) as needed UNTIL lab directed dosing possible.

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	Octaplasma 10-20mL/kg per dose
Fibrinogen <1.5 g/L	FC 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

7
Limit use of crystalloids
8
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/Kg IV (max 3g)
9
Reverse anticoagulation if applicable
Thrombin/ Factor Xa inhibitors or Heparins
Consult with hematologist and/or call pharmacy for dosing
10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

Adult patient

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g., caesarean section, intra-operative)?

Yes

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

Fibryga and Octaplex indicated

SOURCE

MHP 2.0

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA total dose of 2g IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
6
Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets
Cooler 1
4U RBC
Cooler 2
4U RBC
4U Octaplasma
Cooler 3
4U RBC
2U Octaplasma
Cooler 4+
4U RBC
2U Octaplasma
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*At centers without available fibrinogen testing: the clinician may administer Fibryga based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBCs
INR ≥ 1.8
4U Octaplasma
Fibrinogen < 1.5
4g Fibryga
Platelets < 50
Platelets 1 adult dose
Ionized calcium <1.15
Calcium chloride 1g or Calcium gluconate 3g

ROTEM triggers if available
If
Then
EXTEM CT > 80
4U Octaplasma
EXTEM A10 < 35
Platelets 1 adult dose
FIBTEM A10 < 8-10
4g Fibryga
7
Limit use of crystalloids
8
Calcium chloride 1g IV

9

Reverse anticoagulation if applicable

Warfarin	Octaplex 2000 IU IV over 10 min Vitamin K 10mg IV over 10 min
Dabigatran	Idarucizumab 5g IV over 10 min
Apixaban Rivaroxaban Edoxaban	PCC 2000 IU IV over 10 min Repeat in 1 hour if bleeding continues
Heparins	Call pharmacy for protamine dosing

10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

Yes

Step 2 of 3

Assessment every 30-60 minutes

1
Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable?
2
Is the next cooler needed?
3
Is patient’s core temperature >36°C?
4
Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?
5
Administer calcium chloride 1g IV for every 4 RBC or ionized calcium < 1.15L
6
Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)
7
Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)
8
Switch to group specific blood products when able

Can the MHP be deactivated?

Yes

Step 3 of 3

Termination:

1
Deactivate MHP as per local policy
2
Perform bedside termination checklist
3
Inform family member and SDM of needing MHP
4
Ensure coolers and unused MHP components are returned to transfusion medicine lab ASAP
5
Complete documentation and hand-over

Algorithm complete

Reset to start over or to select another journey

No

Last updated: 16-JUL-2026

Fibryga indicated and Octaplex not indicated

SOURCE

MHP 2.0

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA total dose of 2g IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
6
Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets
Cooler 1
4U RBC
Cooler 2
4U RBC
4U Octaplasma
Cooler 3
4U RBC
2U Octaplasma
Cooler 4+
4U RBC
2U Octaplasma
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*At centers without available fibrinogen testing: the clinician may administer Fibryga based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBCs
INR ≥ 1.8
4U Octaplasma
Fibrinogen < 1.5
4g Fibryga
Platelets < 50
Platelets 1 adult dose
Ionized calcium <1.15
Calcium chloride 1g or Calcium gluconate 3g

ROTEM triggers if available
If
Then
EXTEM CT > 80
4U Octaplasma
EXTEM A10 < 35
Platelets 1 adult dose
FIBTEM A10 < 8-10
4g Fibryga
7
Limit use of crystalloids
8
Calcium chloride 1g IV
9
Reverse anticoagulation if applicable
Dabigatran
Idarucizumab 5g IV over 10 min
Apixaban
Rivaroxaban
Edoxaban
PCC 2000 IU IV over 10 min
Repeat in 1 hour if bleeding continues
Heparins
Call pharmacy for protamine dosing
10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

No

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

Octaplex indicated and Fibryga not indicated

SOURCE

MHP 2.0

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA total dose of 2g IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
6
Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets
Cooler 1
4U RBC
Cooler 2
4U RBC
4U Octaplasma
Cooler 3
4U RBC
2U Octaplasma
Cooler 4+
4U RBC
2U Octaplasma
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*At centers without available fibrinogen testing: the clinician may administer Fibrinogen based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBCs
INR ≥ 1.8
4U Octaplasma
Fibrinogen < 1.5
4g FC
Platelets < 50
Platelets 1 adult dose
Ionized calcium <1.15
Calcium chloride 1g or Calcium gluconate 3g

ROTEM triggers if available
If
Then
EXTEM CT > 80
4U Octaplasma
EXTEM A10 < 35
Platelets 1 adult dose
FIBTEM A10 < 8-10
4g FC
7
Limit use of crystalloids
8
Calcium chloride 1g IV

9

Reverse anticoagulation if applicable

Warfarin	Octaplex 2000 IU IV over 10 min Vitamin K 10mg IV over 10 min
Dabigatran	Idarucizumab 5g IV over 10 min
Apixaban Rivaroxaban Edoxaban	PCC 2000 IU IV over 10 min Repeat in 1 hour if bleeding continues
Heparins	Call pharmacy for protamine dosing

10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

No

Last updated: 16-JUL-2026

Fibryga and Octaplex not indicated

SOURCE

MHP 2.0

Step 1 of 3

Initial management

1
Identify source, attempt local control of hemorrhage, and engage definitive hemorrhage control staff (i.e. trauma surgeon/OR/IR)
2
Obtain IV/IO access
3
Consider TXA total dose of 2g IV/IO
4
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
5
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
6
Transfuse 1U RBC with rapid infuser as needed for blood pressure or hemoglobin targets
Cooler 1
4U RBC
Cooler 2
4U RBC
4U Octaplasma
Cooler 3
4U RBC
2U Octaplasma
Cooler 4+
4U RBC
2U Octaplasma
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*At centers without available fibrinogen testing: the clinician may administer Fibrinogen based on clinical evidence of microvascular coagulopathy (e.g. oozing from IV sites) or profound hemodynamic instability where hypofibrinogenemia is predicted.

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBCs
INR ≥ 1.8
4U Octaplasma
Fibrinogen < 1.5
4g FC
Platelets < 50
Platelets 1 adult dose
Ionized calcium <1.15
Calcium chloride 1g or Calcium gluconate 3g

ROTEM triggers if available
If
Then
EXTEM CT > 80
4U Octaplasma
EXTEM A10 < 35
Platelets 1 adult dose
FIBTEM A10 < 8-10
4g FC
7
Limit use of crystalloids
8
Calcium chloride 1g IV
9
Reverse anticoagulation if applicable
Dabigatran
Idarucizumab 5g IV over 10 min
Apixaban
Rivaroxaban
Edoxaban
PCC 2000 IU IV over 10 min
Repeat in 1 hour if bleeding continues
Heparins
Call pharmacy for protamine dosing
10
Call for definitive bleeding control (OR, angio, endoscopy)
11
Transfer for definitive bleeding control

Initial management complete?

Community/ smaller hospital setting that cannot provide plasma

What type of patient is being managed?

Pediatric patient

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g., caesarean section, intra-operative)?

Yes

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

Source

MHP 2.0

Fibryga and Octaplex approved in Canada for this use

Step 1 of 3

Initial management

1
Call for early transfer to pediatric trauma hospital and engage appropriate transport service
2
Identify source and attempt local control of hemorrhage
3
Obtain IV/IO access
4
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).

7

Transfuse all of “Cooler 1” RBCs (20 ml/Kg per dose) BEFORE “Cooler 2” UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2+
> 40kg	4U RBC	4U RBC, 2000 IU Octaplex, 4g Fibryga
31-40kg	3U RBC	3U RBC, 1000 IU Octaplex, 2g Fibryga
10-30kg	2U RBC	2U RBC, 1000 IU Octaplex, 2g Fibryga
<10kg	1U RBC	1U RBC, 500 IU Octaplex, 1g Fibryga

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	Octaplex 25 IU/kg (rounded to closest 500 IU), max 2000 IU
Fibrinogen <1.5 g/L	Fibryga 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

8
Limit use of crystalloids
9
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/kg IV (max 3g)

10

Reverse anticoagulation if applicable

Warfarin

Vitamin K 1-10mg (neonate to adolescent) IV over 10 min & Octaplex 15IU/kg for INR <3 (or unknown) & 30IU/kg if INR ≥ 3

(max 2000 IU)

Thrombin/ Factor Xa inhibitors or Heparins

Consult with hematologist and/or call pharmacy for dosing

11
Transfer for definitive bleeding control

As directed by protocol

Is management complete?

Yes

Step 2 of 3

Assessment every 30-60 minutes

1
Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable?
2
Is patient’s core temperature >36°C?
3
Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?
4
Administer calcium chloride 20 mg/kg (max 1 g) or gluconate 60 mg/Kg IV (max 3 g) after each RBC equivalent of one cooler transfused or ionized calcium <1.15 mmol/L
5
Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)
6
Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)
7
Switch to group specific blood products when able

As directed by protocol

Can the MHP be deactivated?

No

Last updated: 16-JUL-2026

Source

MHP 2.0

Fibryga is approved in Canada for this use

No PCC is approved in Canada for this indication; use is guideline-supported

Step 1 of 3

Initial management

1
Call for early transfer to pediatric trauma hospital and engage appropriate transport service
2
Identify source and attempt local control of hemorrhage
3
Obtain IV/IO access
4
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).

7

Transfuse all of “Cooler 1” RBCs (20 ml/Kg per dose) BEFORE “Cooler 2” UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2+
> 40kg	4U RBC	4U RBC, 2000 IU PCC, 4g Fibryga
31-40kg	3U RBC	3U RBC, 1000 IU PCC, 2g Fibryga
10-30kg	2U RBC	2U RBC, 1000 IU PCC, 2g Fibryga
<10kg	1U RBC	1U RBC, 500 IU PCC, 1g Fibryga

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	PCC 25 IU/kg (rounded to closest 500 IU), max 2000 IU
Fibrinogen <1.5 g/L	Fibryga 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

8
Limit use of crystalloids
9
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/kg IV (max 3g)
10
Reverse anticoagulation if applicable
Thrombin/ Factor Xa inhibitors or Heparins
Consult with hematologist and/or call pharmacy for dosing
11
Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

No

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

MHP 2.0

Octaplex is approved in Canada for this use

No FC is approved in Canada for this indication; use is guideline-supported

Step 1 of 3

Initial management

1
Call for early transfer to pediatric trauma hospital and engage appropriate transport service
2
Identify source and attempt local control of hemorrhage
3
Obtain IV/IO access
4
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).

7

Transfuse all of “Cooler 1” RBCs (20 ml/Kg per dose) BEFORE “Cooler 2” UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2+
> 40kg	4U RBC	4U RBC, 2000 IU Octaplex, 4g FC
31-40kg	3U RBC	3U RBC, 1000 IU Octaplex, 2g FC
10-30kg	2U RBC	2U RBC, 1000 IU Octaplex, 2g FC
<10kg	1U RBC	1U RBC, 500 IU Octaplex, 1g FC

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	Octaplex 25 IU/kg (rounded to closest 500 IU), max 2000 IU
Fibrinogen <1.5 g/L	FC 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

8
Limit use of crystalloids
9
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/kg IV (max 3g)

10

Reverse anticoagulation if applicable

Warfarin	Vitamin K 1-10mg (neonate to adolescent) IV over 10 min & Octaplex 15IU/kg for INR <3 (or unknown) & 30IU/kg if INR ≥ 3 (max 5000 IU)
Thrombin/ Factor Xa inhibitors or Heparins	Consult with hematologist and/or call pharmacy for dosing

11
Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

No

Last updated: 16-JUL-2026

MHP 2.0

No PCC or FC is approved in Canada for this indication; use is guideline-supported

Step 1 of 3

Initial management

1
Call for early transfer to pediatric trauma hospital and engage appropriate transport service
2
Identify source and attempt local control of hemorrhage
3
Obtain IV/IO access
4
Consider TXA 30 mg/kg (max 2 g) and infusion of 10 mg/kg/hr IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).

7

Transfuse all of “Cooler 1” RBCs (20 ml/Kg per dose) BEFORE “Cooler 2” UNLESS lab results direct otherwise

Weight	Cooler 1	Cooler 2+
> 40kg	4U RBC	4U RBC, 2000 IU PCC, 4g FC
31-40kg	3U RBC	3U RBC, 1000 IU PCC, 2g FC
10-30kg	2U RBC	2U RBC, 1000 IU PCC, 2g FC
<10kg	1U RBC	1U RBC, 500 IU PCC, 1g FC

*Administer O Negative for females, otherwise O Positive RBC

Laboratory guided transfusion once available and bleeding rate controlled

If	Then
Hgb < 80g/L	RBC 20ml/kg per dose (max 1 unit, ~287mL)
INR ≥ 1.8	PCC 25 IU/kg (rounded to closest 500 IU), max 2000 IU
Fibrinogen <1.5 g/L	FC 50mg/kg, max 4g (max 2g if <30kg)
Platelets < 50 x 10⁹	Platelets 10 ml/kg per dose

8
Limit use of crystalloids
9
Administer calcium chloride 20 mg/kg (max 1g) or calcium gluconate 60 mg/kg IV (max 3g)
10
Reverse anticoagulation if applicable
Thrombin/ Factor Xa inhibitors or Heparins
Consult with hematologist and/or call pharmacy for dosing
11
Transfer for definitive bleeding control

As directed by protocol

Is initial management complete?

Adult patient

Does the uncontrolled severe bleeding arise in the course of a surgical intervention (e.g., caesarean section, intra-operative)?

Yes

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

SOURCE

MHP 2.0

Fibryga and Octaplex indicated

Step 1 of 3

Initial management

1
Call for early transfer to tertiary care center and engage appropriate transport service
2
Identify source and attempt local control of hemorrhage
3
Obtain IV/IO access
4
Consider TXA total dose of 2g IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
7
Transfuse 4U RBC with rapid infuser
Cooler 1
4U RBC
Cooler 2+
RBC 4U
Octaplex 2000 IU
Fibryga 4g
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*Platelets and Fibryga should be transfused based on hourly laboratory test results.

*Fibryga should be given concurrently with Octaplex unless the fibrinogen level is known to be >1.5g/L

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBC 2U
INR ≥ 1.8
Octaplasma 4U
Fibrinogen < 1.5
Fibryga 4g
Platelets < 50
Platelets 1 adult dose
Ionized calcium <1.15
Calcium chloride 1g or Calcium gluconate 2g IV
8
Limit use of crystalloids
9
Calcium chloride 1g IV

10

Reverse anticoagulation if applicable

Warfarin	Octaplex 2000 IU IV over 10 min Vitamin K 10mg IV over 10 min
Dabigatran	Idarucizumab 5g IV over 10 min If unavailable, PCC 2000 IU IV over 10 mins
Apixaban Rivaroxaban Edoxaban	Specific reversal agent If unavailable, PCC 2000 IU IV over 10 mins Repeat in 1 hour if bleeding continues
Heparins	Call pharmacy for protamine dosing

11
Transfer patient via EMS/ critical care ambulance for definitive bleeding control

Initial management complete?

yes

Step 2 of 3

Assessment every 30-60 minutes

1
Can MHP be turned off? Can patient be switched to laboratory directed transfusion? Consider: bleeding controlled? Hemodynamics stable?
2
Is the next cooler needed?
3
Is patient’s core temperature >36°C?
4
Are blood samples collected q30-60 mins? Is the transfusion of products adjusted?
5
Administer calcium chloride 1g IV for every 4 RBC or ionized calcium < 1.15L
6
Monitor for complications (ex. hyperkalemia, hypothermia and volume overload)
7
Is resuscitation adequate? (ex. hemodynamics, lactate, base deficit, account for traumatic brain injury)
8
Switch to group specific blood products when able

Can the MHP be deactivated?

Yes

Step 3 of 3

Termination:

1
Deactivate MHP as per local policy
2
Perform bedside termination checklist
3
Inform family member and SDM of needing MHP
4
Ensure coolers and unused MHP components are returned to transfusion medicine lab ASAP
5
Complete documentation and hand-over

Algorithm complete

Reset to start over or to select another journey

No

Last updated: 16-JUL-2026

SOURCE

MHP 2.0

Fibryga indicated, Octaplex not indicated

Step 1 of 3

Initial management

1
Call for early transfer to tertiary care center and engage appropriate transport service
2
Identify source and attempt local control of hemorrhage
3
Obtain IV/IO access
4
Consider TXA total dose of 2g IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
7
Transfuse 4U RBC with rapid infuser
Cooler 1
4U RBC
Cooler 2+
RBC 4U
PCC 2000 IU
Fibryga 4g
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*Platelets and Fibryga should be transfused based on hourly laboratory test results.

*Fibryga should be given concurrently with PCC unless the fibrinogen level is known to be >1.5g/L

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBC 2U
INR ≥ 1.8
Octaplasma 4U
Fibrinogen < 1.5*
Fibryga 4g
Platelets < 50
Platelets 1 adult dose
Ionized calcium <1.15
Calcium chloride 1g or Calcium gluconate 2g IV
*Less than 2.0 for post-partum hemorrhage
8
Limit use of crystalloids
9
Calcium chloride 1g IV

10

Reverse anticoagulation if applicable

Dabigatran

Idarucizumab 5g IV over 10 min

If unavailable, PCC 2000 IU IV over 10 mins

Apixaban

Rivaroxaban

Edoxaban

Specific reversal agent

If unavailable, PCC 2000 IU IV over 10 mins

Repeat in 1 hour if bleeding continues

Heparins

Call pharmacy for protamine dosing

11
Transfer patient via EMS/ critical care ambulance for definitive bleeding control

Initial management complete?

No

Is the coagulopathy attributable to a vitamin K antagonist (e.g., warfarin) requiring rapid reversal or bleeding in cardiac surgery?

Yes

Last updated: 16-JUL-2026

MHP 2.0

Octaplex indicated, Fibryga not indicated

Step 1 of 3

Initial management

1
Call for early transfer to tertiary care center
2
Identify source and attempt local control of hemorrhage and engage appropriate transport service
3
Obtain IV/IO access
4
Consider TXA total dose of 2g IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
7
Transfuse 4U RBC with rapid infuser
Cooler 1
4U RBC
Cooler 2+
RBC 4U
Octaplex 2000 IU
FC 4g
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*Platelets and fibrinogen should be transfused based on hourly laboratory test results.

*Fibrinogen should be given concurrently with Octaplex unless the fibrinogen level is known to be >1.5g/L

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBC 2U
INR ≥ 1.8
Octaplasma 4U
Fibrinogen < 1.5
FC 4g
Platelets < 50
Platelets
Ionized calcium <1.15
Calcium chloride 1g
8
Limit use of crystalloids
9
Calcium chloride 1g IV

10

Reverse anticoagulation if applicable

Warfarin	Octaplex 2000 IU IV over 10 min Vitamin K 10mg IV over 10 min
Dabigatran	Idarucizumab 5g IV over 10 min If unavailable, PCC 2000 IU IV over 10 mins
Apixaban Rivaroxaban Edoxaban	Specific reversal agent If unavailable, PCC 2000 IU IV over 10 mins Repeat in 1 hour if bleeding continues
Heparins	Call pharmacy for protamine dosing

11
Transfer patient via EMS/ critical care ambulance for definitive bleeding control

Initial management complete?

No

Last updated: 16-JUL-2026

SOURCE

MHP 2.0

Fibryga and Octaplex not indicated

Step 1 of 3

Initial management

1
Call for early transfer to tertiary care center and engaged appropriate transport service
2
Identify source and attempt local control of hemorrhage
3
Obtain IV/IO access
4
Consider TXA total dose of 2g IV/IO
5
Measure temperature, prevent hypothermia and achieve normothermia (>36⁰C).
6
Complete laboratory testing at baseline and at a minimum hourly until the protocol is terminated.

I.e. CBC, PT/INR, aPTT, fibrinogen, electrolytes, calcium (ionized), arterial or venous blood gas (pH and base excess), lactate, blood glucose, group and screen (with initial labs).
7
Transfuse 4U RBC with rapid infuser
Cooler 1
4U RBC
Cooler 2+
RBC 4U
PCC 2000 IU
FC 4g
*Administer O Negative RBC for females <45, otherwise O Positive RBC

*Platelets and fibrinogen should be transfused based on hourly laboratory test results.

*Fibrinogen should be given concurrently with PCC unless the fibrinogen level is known to be >1.5g/L

Laboratory guided transfusion once available and bleeding rate controlled
If
Then
Hgb < 80
RBC 2U
INR ≥ 1.8
Octaplasma 4U
Fibrinogen < 1.5
FC 4g
Platelets < 50
Platelets 1 adult dose
Ionized calcium <1.15
Calcium chloride 1g or Calcium gluconate 2g IV
8
Limit use of crystalloids
9
Calcium chloride 1g IV

10

Reverse anticoagulation if applicable

Dabigatran

Idarucizumab 5g IV over 10 min

If unavailable, PCC 2000 IU IV over 10 mins

Apixaban

Rivaroxaban

Edoxaban

Specific reversal agent

If unavailable, PCC 2000 IU IV over 10 mins

Repeat in 1 hour if bleeding continues

Heparins

Call pharmacy for protamine dosing

11
Transfer patient via EMS/ critical care ambulance for definitive bleeding control

Initial management complete?

Cardiac Surgery

What is your current situation?

Preparing for a bleed

Last updated: 16-JUL-2026

SOURCE

FARES-II
FIBRES
TGH algorithm
SCA, 2019

Step 1 of 3

PATIENT COMING OFF BYPASS

1
Measure CBC
2
If CPB duration is >150 minutes, measure ROTEM/TEG/ INR (based on available testing)

Step 2 of 3

AFTER COMING OFF BYPASS

1
Administer Protamine when appropriate to reverse Heparin at <1mg per 100 U of the initial heparin dose
2
If ACT is not normalized ± 10% of baseline, administer additional protamine
3
Optimize temperature (>36 C), pH ( >7.2), iCa++ (>1mmol/L) and Hb (>7.5 g/dL)
4
Continue antifibrinolytics and consider ANH, mini circuits, retrograde priming and cell salvage

Step 3 of 3

ASSESS BLEEDING SEVERITY SCORE (BSS)

1
If BSS < 2 no action
2
If BSS ≥ 2, measure ROTEM/ TEG/ INR (based on available testing) if was not measured or was normal at re-warming

Grade 2 bleeding (video 3)https://www.surgjournal.com/article/S0039-6060(16)30605-5/fulltext

What is the bleeding severity score?

BSS < 2

No action

Algorithm complete

Reset to start over or to select another journey.

BSS ≥ 2

What point-of-care testing is available?

ROTEM

Last updated: 16-JUL-2026

FARES-II
FIBRES
TGH Algorithm
SCA, 2019

Fibryga and Octaplex indicated

ROTEM thresholds

IfAdminister

[HEPTEM CT/ INTEM CT] <0.9
Protamine
10-50 mg prn
FIBTEM A10 ≤ 10mm
4g, re-dose as needed
CT-EXTEM > 100s
1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if ECMO or HIT are present. Re-dose only once, then use Octaplasma if needed..
EXTEM A10 < 40 mm
Platelets
1 pool, re-dose as needed
INTEM or EXTEM ML > 7% at 30 min or >15% at 60 min
Administer Aminocaproic Acid or Tranexamic Acid
Dose and re-dose according to what was administered so far. Max of 50-100 mg/kg
Hemoglobin concentration <80 g/L
RBC
One unit at a time, followed by clinical reassessment

If

[HEPTEM CT/ INTEM CT] <0.9

Administer

Protamine

10-50 mg prn

If

FIBTEM A10 ≤ 10mm

Administer

4g, re-dose as needed

If

CT-EXTEM > 100s

Administer

1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if ECMO or HIT are present. Re-dose only once, then use Octaplasma if needed..

If

EXTEM A10 < 40 mm

Administer

Platelets

1 pool, re-dose as needed

If

INTEM or EXTEM ML > 7% at 30 min or >15% at 60 min

Administer

Administer Aminocaproic Acid or Tranexamic Acid

Dose and re-dose according to what was administered so far. Max of 50-100 mg/kg

If

Hemoglobin concentration <80 g/L

Administer

RBC

One unit at a time, followed by clinical reassessment

ALWAYS

Check and optimize

1
Temperature >36 C
2
pH > 7.2
3
iCa > 1.0mmol/L
4
Hb > 7.5 g/dL

If excessive bleeding persists despite normal ROTEM, consider surgical re-exploration

Transfusion complete and bleeding stabilized?

Yes

Post infusion management

Repeat routine lab assays (i.e. CBC/PT/PTT/INT/Fibrinogen)

Management

IFTHEN

Patient is stable, Hb < 80 g/L
Monitor and evaluate volume status. Consider administering one RBC unit at a time followed by clinical reassessment if appropriate
If patient is unstable, Hb < 90g/L
Administer one RBC unit at a time followed by clinical reassessment

IF

Patient is stable, Hb < 80 g/L

THEN

Monitor and evaluate volume status. Consider administering one RBC unit at a time followed by clinical reassessment if appropriate

IF

If patient is unstable, Hb < 90g/L

THEN

Administer one RBC unit at a time followed by clinical reassessment

Management algorithm complete - Reset to start over or to select another journey

TEG 5000

Last updated: 16-JUL-2026

SOURCE

FARES-II
FIBRES
SCA, 2019

Fibryga and Octaplex indicated

TEG 5000 thresholds

IfAdminister

TEG R > hTEG R x 1.25
Protamine
at 10-50 mg prn
MA < 40 mm and FF > 8 mm
4g, re-dose as needed
Hteg R > 12 min
1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if ECMO or HIT are present. Re-dose only once, then use Octaplasma if needed.
MA < 40 mm AND FF < 8 mm
Platelets
1 pool, re-dose as needed
LY30 > 7.5%
Aminocaproic Acid or Tranexamic acid
Dose and re-dose according to what was administered so far. Max of 50-100 mg/kg
Hemoglobin concentration <80 g/L
RBC
One unit at a time, followed by clinical reassessment

If

TEG R > hTEG R x 1.25

Administer

Protamine

at 10-50 mg prn

If

MA < 40 mm and FF > 8 mm

Administer

4g, re-dose as needed

If

Hteg R > 12 min

Administer

1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if ECMO or HIT are present. Re-dose only once, then use Octaplasma if needed.

If

MA < 40 mm AND FF < 8 mm

Administer

Platelets

1 pool, re-dose as needed

If

LY30 > 7.5%

Administer

Aminocaproic Acid or Tranexamic acid

Dose and re-dose according to what was administered so far. Max of 50-100 mg/kg

If

Hemoglobin concentration <80 g/L

Administer

RBC

One unit at a time, followed by clinical reassessment

ALWAYS

Check and optimize

1
Temperature >36 C
2
pH > 7.2
3
iCa > 1.0mmol/L
4
Hb > 7.5 g/dL

If excessive bleeding persists despite normal TEG 5000, consider surgical re-exploration

Transfusion complete and bleeding stabilized?

Neither available

Last updated: 16-JUL-2026

SOURCE

FARES-II
FIBRES
SCA, 2019

Fibryga and Octaplex indicated

Neither available

IfAdminister

ACT > baseline
Protamine
10-50 mg prn
If fibrinogen levels <150 mg/dL
4g, re-dose as needed
INR ≥ 1.5
1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if ECMO or HIT are present. Re-dose only once, then use Octaplasma if needed.
Platelet count < 100,000
Platelets
1 pool, redose as needed
If bleeding persists
Administer Aminocaproic Acid or Tranexamic Acid
Dose and re-dose according to what was administered so far. Max of 50-100 mg/kg
Hemoglobin concentration <80 g/L
RBC
One unit at a time, followed by clinicial reassessment

If

ACT > baseline

Administer

Protamine

10-50 mg prn

If

If fibrinogen levels <150 mg/dL

Administer

4g, re-dose as needed

If

INR ≥ 1.5

Administer

1500 IU if IBW < 60kg and 2000 IU if IBW ≥ 60kg. Not recommended if ECMO or HIT are present. Re-dose only once, then use Octaplasma if needed.

If

Platelet count < 100,000

Administer

Platelets

1 pool, redose as needed

If

If bleeding persists

Administer

Administer Aminocaproic Acid or Tranexamic Acid

Dose and re-dose according to what was administered so far. Max of 50-100 mg/kg

If

Hemoglobin concentration <80 g/L

Administer

RBC

One unit at a time, followed by clinicial reassessment

ALWAYS

Check and optimize

1
Temperature >36 C
2
pH > 7.2
3
iCa > 1.0mmol/L
4
Hb > 7.5 g/dL

If excessive bleeding persists despite normal labs, consider surgical re-exploration

Transfusion complete and bleeding stabilized?

Post-Partum

Coming Soon!

We’re working hard to bring this feature to life. Check back soon for updates.

CrCl ≥ 50 mL/ min	Half-life is 7-17 hours
CrCl 30– 49 mL/min	Half-life is 17 – 20 hours

CrCl ≥ 50 mL/ min	Half-life is 10-14 hours
CrCl 30– 49 mL/min

CrCl ≥ 50 mL/ min	Half-life is 7-11 hours
CrCl 30– 49 mL/min	Half-life is 7-11 hours

CrCl ≥ 50 mL/ min	Half-life is 8-12 hours
CrCl 30– 49 mL/min	Half-life is 8 – 12 hours

If	Then
Hgb < 80	RBCs
INR ≥ 1.8	4U Octaplasma
Fibrinogen < 1.5	4g Fibryga
Platelets < 50	Platelets 1 adult dose
Ionized calcium <1.15	Calcium chloride 1g or Calcium gluconate 3g

If	Then
EXTEM CT > 80	4U Octaplasma
EXTEM A10 < 35	Platelets 1 adult dose
FIBTEM A10 < 8-10	4g Fibryga

If	Then
Hgb < 80	RBC 2U
INR ≥ 1.8	Octaplasma 4U
Fibrinogen < 1.5	Fibryga 4g
Platelets < 50	Platelets 1 adult dose
Ionized calcium <1.15	Calcium chloride 1g or Calcium gluconate 2g IV

DOAC

Bleed on DOAC

Minor Bleeding

Yes

Minor bleeding on DOAC

Yes

Bleeding resolved

Scenario complete

Clinically relevant non-major bleeding

Yes

Apixaban

Next

Next

Clinically relevant non-major bleed on Apixaban

Next

Clinically relevant non-major bleed on Apixaban

Next

Clinically relevant non-major bleed on Apixaban

Yes

Bleeding resolved

Scenario complete

Edoxaban

Next

Next

Clinically relevant non-major bleed on Edoxaban

Next

Clinically relevant non-major bleed on Edoxaban

Next

Clinically relevant non-major bleed on Edoxaban

Rivaroxaban

Next

Next

Clinically relevant non-major bleed on Rivaroxaban

Next

Clinically relevant non-major bleed on Rivaroxaban

Next

Clinically relevant non-major bleed on Rivaroxaban

Dabigatran

Next

Next

Clinically relevant non-major bleed on Dabigatran

Next

Clinically relevant non-major bleed on Dabigatran

Next

Clinically relevant non-major bleed on Dabigatran

Major bleeding

Yes

Apixaban

Next

Next

Major bleed on Apixaban

Next

Major bleed on Apixaban

Next

Major bleed on Apixaban

Yes

Bleeding resolved

Algorithm complete

Edoxaban

Next

Next

Major bleed on Edoxaban

Next

Major bleed on Edoxaban

Next

Major bleed on Edoxaban

Yes

Bleeding resolved

Algorithm complete

Rivaroxaban

Next

Next

Major bleed on Rivaroxaban

Next

Major bleed on Rivaroxaban

Next

Major bleed on Rivaroxaban

Yes

Bleeding resolved

Algorithm complete